As healthcare rightly moves towards a model of rewarding quality over quantity, the issue of how best to reimburse physicians is also taking a front seat. If not fee-for-service, then how best to judge and reward quality? In this new value-based system of the future, some members of the medical community have been increasingly advocating for billing purely for time. In fact, over the years I’ve heard many doctors (usually on bad days) remark that they have just spent a long time on a specific non-reimbursable task—like an extended meeting or phone call—and how they wish that they could have “just billed directly for time exactly like lawyers do”. The argument behind this model is that it will adequately reward doctors for actually spending time on patient care tasks (for obvious reasons, this applies mainly to medical specialties rather than surgical ones). More time equals a higher reimbursement, and that sounds fair, right? I can understand sentiments such as these in the midst of a frustrating day, but I could not disagree more with the suggested solution. In fact, I must confess that even the idea makes me balk. The way the legal profession operates shouldn’t be our role model in an industry like ours. It would be a disaster if doctors start expecting to be rewarded directly according to time spent with patients.
Let me say why, by drawing on a personal experience from the above-cited legal profession. A couple of years ago, I met with a local attorney at their office regarding a minor matter. The attorney seemed personable and friendly, and the advice was excellent. A week or so later, a follow-up question came to mind. I called and left a message for an answer. The attorney soon got back to me and the question was answered in about 5 minutes. A few days later I was somewhat shocked to receive a letter in the mail that was billing me directly for this “time”, also including the “research needed” which equated to about 15 minutes (and, looking back, it was the most basic of questions). I dutifully paid my dues, but was quite surprised to be charged for what I thought was a quick follow up phone call. But this makes me think, what if doctors acted in the same way? A similar method of billing our patients may sound extreme, but would be exactly what happens in a purely time based system where we accounted for all our conversation time. We should never become like the legal profession in this respect. The current inpatient billing system with broad blocks of time, such as 30 minutes, is one thing—but the extreme of this would be unthinkable. Even an employed physician model that involves an hourly pay rate (which is not necessarily the best way either, as a salary is more befitting of a professional) would still be better than billing for exact increments of time.
What if we decided to spend a few extra minutes trying to educate our patient about their illness? What if we decided to drop by a patient room to check up on them out of a sense of duty? Or what if we bump into a family member in the corridor and stop to discuss their loved ones’ progress? I certainly don’t want to work in a profession where the person we are talking to is worried about some type of “dollar stopclock” that’s ticking for their physicians’ precious time. Could the doctor be talking to me with dollar signs in their eyes? In such an environment, patients may even become suspicious of doctors who are spending extra time with them. No patient should ever get a bill that quotes “10 minutes of doctor time equals a certain dollar amount”. It would be to the great detriment of the whole medical profession, eroding trust between doctor and patient. We could also experience a kickback from patients, who may well themselves start trying to rush us through our time with them!
I recently read an article in a major medical publication that was debating whether “email consults” should be billed. I understood the logic behind it, but the next natural question is should we start billing for email advice to patients as well? To draw another comparison from a service-based industry, think of how your realtor or mortgage broker works with you when you buy a house. They get paid a certain fee, and at least in my experience, are always available with questions. I’ve appreciated how they’ve guided me through what is often a complex and emotional experience (sound familiar to all of us in healthcare?). I think it would be awful if every time I emailed them a question, I was sent a bill! It takes the whole meaning away from the relationship, and isn’t the way professionals should work. At a time of tumultuous change in healthcare, doctors mustn’t go down this route. Collectively, a red line should be drawn to say that there’s no way we will become focused on billing for exact minute values of time. While we may not yet have all the answers on how best to allocate reimbursements in the healthcare system of the future, that isn’t one of them. We should keep our respect as a noble profession and do everything possible to retain the special bond between doctor and patient. Because for doctors, duty to the cause of healing comes first. That’s what makes us different.